California NPs

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Hey everybody, I'm a psychiatric NP student at UT-Austin. I have a year left in my program. I'm interested in practicing in a state that allows for independent or mostly independent practice, and I'm also interested in moving to California.

I'm seeing from the Pearson Report that California has a rating of C... and I'm seeing some limiting regulatory language from the California legislature and BRN. It's still an improvement from Texas' D, where there seems to be a wide range of APRN experiences based on the relationship with the APRN's "collaborating" (="supervising") physician. Although I don't like Texas' regulatory climate, I love the energy of Texas APRNs, at least from my POV in Austin and at UT, where the capitol is next door and APRNs are pushing long and hard for autonomous practice in this legislative session.

I understand that experiences vary individually, but I was wondering if anybody had any comments about what the advanced practice environment is like generally in California. What is the political climate like for nurses? Do you feel like you have a lot of autonomy to do your job? What do you like and not like about being an APRN in California?

Do like I did and step right next door to New Mexico where you are totally independent. I'm also still in shock that the NM BON issued my license in 8 business days and even called me to tell me it had been issued!

I'm in California, though I'm really still relatively new to the state having moved from Michigan in late 2009. California, is rather restrictive in my opinion. The Board of Registered Nursing (BRN) which regulates the practice of NP's have the view that NP's, despite their advanced standing in terms of education and training, have no additional role above and beyond that of an RN. In order for a nurse practitioner to perform the advanced roles that we did get trained for, a Standardized Procedure document signed with a physician entity is required which basically outlines the "medical" or "physician" centric (sic) responsibilities we could do such as diagnosing and treating. The Standardized Procedure even goes as far as to require a "formulary" of medications we could "furnish" to patients. That also brings me to the term "furnish" which the BRN conjured up as a word to denote the act of prescribing that we NP's do. God forbid, we use the term "prescribe" for this role for we are not physicians! The BRN grants an NP Furnishing License in addition to the NP certificate and only when the NPF License is in place could an NP "furnish". Sounds confusing? not really once you get the hang of it.

Michigan was different for me. It got a low score on the Pearson Report but actually, I think that state is more permissive of NP independence. The problem (or lack of a problem) with Michigan is that the state does not have a specified Nurse Practitioner scope of practice act in its laws. The absence of such scope of practice law leaves the issue up in the air and does not prohibit nor allow full independence for NP's. The only thing holding back NP's from independently practicing in that state is the issue of prescriptive authority. Because there are no NP practice act, the act of prescribing defaults back to the RN role and in the State of Michigan, a physician can delegate the act of prescribing to an RN. Of course, not many physicians in their right minds in Michigan would delegate prescribing to an RN but they would have no problem delegating that to an NP. The caveat in this being that a collaborative agreement is required for a nurse practitioner to prescribe.

I hear Texas is not nearly as bad. However, I do love the weather in Northern California and I can't find a better city to live in than San Francisco at the current time.

Do like I did and step right next door to New Mexico where you are totally independent. I'm also still in shock that the NM BON issued my license in 8 business days and even called me to tell me it had been issued!

As far as California goes, it should rate a "D" or perhaps a "D-". As Juan posted, NP's in this state have no scope of practice. They are not recognized above and beyond a RN and they have no prescriptive authority - only furnishing, which is to "make medications" and devices "available".

Juan, I can't believe that NPs don't have a wider scope than an RN, sounds even worse than in Texas! Totally ridiculous. I was thinking of moving to SF, am actually headed there today. The West Coast has really captured my interest... but I'm thinking maybe Seattle or Portland would be a better fit.

Here, at least, we can be "delegated" prescriptive and diagnostic authority... some Texas NPs have a lot of autonomy, and the pay can be excellent, but it's all very dependent on the relationship with a physician. And here in Austin, what I'm hearing is that many psychiatrists refuse to collaborate with psych NPs, or if they do collaborate, they want 40-60% of the NP's income as their fee. It's totally a racket, but the medical lobby has a vested interest in maintaining the status quo. I'm seeing that perhaps California is the same way.

Dr. Tammy, thanks for the link to the video. I love when the narrator's talking about physician domination of nursing and there's a clip of native americans running around with headdresses on. Too funny! I'd go to New Mexico or Arizona but I've spent my whole life in New Orleans and Texas and need to get out of the summer blast furnace!

I was looking into updates from CANP but can't access their legislative stuff without joining the organization. During the last legislative cycle, were there any bills introduced in the legislature to establish scope of practice? What kind of efforts are going on to combat it, and does it look like they have any chance of success? Here, things looked grim this year, but we amazingly got two bills out of the hostile Senate health/human services and to a couple of Senate committees that'll give us a fair shake.

I am from Seattle but not living there right now. Be prepared for rain, gloomy weather in seattle and portland & overpopulated NPs/PA. There are 3 NP schools & 1 PA school just in seattle dumping NPs/PA left & right (not considering other nearby cities Tacoma which has 2 NP schools itself just south of seattle 30 mins). And every hospitals/clinics/urgent care centers prefer to hire UW prepared NP/PA (#1 nursing school in US & #7 PA program). Also, SPU, SU, PLU, WSU students all compete equally. You either have to have lots of RN experience with excellent preliminary hiring scores or you'll be competing with lots of jobseekers for months. However, if you consider driving or living in other cities excluding seattle you would have a better chance getting a job. The more east you go the easier to get jobs in WA state. Also, alaska is excellent & pays more than seattle/portland but snow sucks (at least for me). Arizona is excellent but too warm (may be like texas though I've never been to texas). Other states to consider new mexico (like zenman said).

True, the major cities in the West Coast are certainly oversaturated from San Diego all the way to Seattle. There is fierce competition for jobs and new grads would easily lose a position to experienced NP's. I came to San Francisco with 5 years of critical care NP experience and that certainly got me the job in critical care here. A colleague of mine in San Francisco with similar years of experience in critical care recently moved to Portland and got a job there. I say gain experience where you can get jobs and move later.

I was looking into updates from CANP but can't access their legislative stuff without joining the organization. During the last legislative cycle, were there any bills introduced in the legislature to establish scope of practice? What kind of efforts are going on to combat it, and does it look like they have any chance of success? Here, things looked grim this year, but we amazingly got two bills out of the hostile Senate health/human services and to a couple of Senate committees that'll give us a fair shake.

CANP just had a management change. I'm not too impressed. I'm the health chair for our local NAACP and we just passed a resolution calling for the removal of barriers to NP practice and for an official, state defined and independent scope of practice for NP's to increase health care access for minority-based populations. I left a half a dozen phone calls for CANP staff as well as their rep lobbyist to let them know. To date, no one has called me back. They feel that "regrouping" versus staying on the offensive is the best MO to an independent pathway. My philosophy is that timing is everything and with each failure, new material is learned in how to try again.

I agree Dr Tammy - CANPs lobbying day is May 2nd and I don't see anything of real importance being targeted. I sent you a pm discussing this further.....

Actually, there is much we can do. I'll give you a call tomorrow.

Also, if any NP's or NP students are out there and are completely disgusted with the present medical technician status of NP's in California coupled with our do-nothing, go-nowhere NP organization and want to put in about 10 hours a month or so to do something about it, send me a pm.

I've been executing a plan over the last six months and its starting to gain real traction in the central valley. The problem: I'm only one NP doing this and the workload is very daunting. Problem #2: Most NP's, at least in my area, are content with the status quo of being a medical assistant with a few additional duties. I know there are others out there who feel the same and are ready to step up in a leadership role to benefit our profession as well as increase health care access for our patients.